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Bills, Bills, Bills: Readers And Tweeters Offer Solace, Solutions And Scoldings

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

2018 was a busy year for KHN, harvesting more than 1,200 medical bills submitted by readers for consideration in our “Bill of the Month” franchise, an investigative partnership with NPR. These monthly dives into patients’ cumbersome bills continue to spawn stories — as well as proposed changes to health care policy by legislators.

Sen. Bernie Sanders (I-Vt.) glommed on to the despair of an Arizona couple consumed by health care debt (“Insured But Still In Debt: 5 Jobs Pulling In $100K A Year No Match For Medical Bills,” Dec. 28).

No one should have to work 120 hours a week or 5 jobs to be able to get the health care they need. We need a health care system that puts people before profits. We need a Medicare for all, single-payer system. https://t.co/p6Nzz16x2J

— Bernie Sanders (@BernieSanders) December 27, 2018

In response to the August “Bill of the Month” feature about a schoolteacher’s $109,000 heart attack, Rep. Lloyd Doggett (D-Texas) tweeted: “When I heard Drew’s story — an Austin teacher saddled with a $100k surprise bill after surgery — I reached out to him to share my concern. We discussed my End Surprise Billing Act legislation, which would end this predatory practice.”

When I heard Drew’s story—an Austin teacher saddled with a $100k surprise bill after surgery—I reached out to him to share my concern. We discussed my End Surprise Billing Act legislation, which would end this predatory practice. https://t.co/34FHOQBa4A

— Lloyd Doggett (@RepLloydDoggett) September 1, 2018

Sanders also shared that story on Facebook, saying: “Our health care system makes absolutely no sense. If you don’t have health insurance, you probably can’t afford to get the care you need. And if you DO have health insurance, in many cases you STILL won’t be able to afford the care you need, on top of paying a monthly premium.”

Outrageous medical bills proved something readers could relate to, as they reviewed our end-of-the-year roundup, Year One Of KHN’s ‘Bill Of The Month’: A Kaleidoscope Of Financial Challenges” (Dec. 21).

Message here – don't get sick! @UTSWIMchief https://t.co/l8R3hAnTYU via @khnews

— David Johnson (@dhjutsw1) January 7, 2019

— Dr. David Johnson, Dallas

Plaudits For ‘Bill Of The Month’ Series

Thank you for publishing these stories. You are doing a public service. I work in health services research and know that the prices charged by manufacturers, hospitals and other providers are arbitrary. The more citizens are informed about this, the more power we have to change how much health care costs in this country.

— Beth Egan, Minneapolis

Patients should look carefully at all their hospital bills – estimates are that half have errors: tests scheduled but not and charged, medicines not taken., consults by doctors who never saw you. Caveat emptor!

— Edward Hoffer MD (@EdwardHoffer1) December 26, 2018

— Dr. Edward Hoffer, Boston

‘Bill Of The Month’: Recourse For Wounded Skier

It seems that the surgeon and the device manufacturer should have paid for Sarah Witter’s second surgery (“After Her Skiing Accident, An Uphill Battle Over Snowballing Bills,” Dec. 18). If she truly followed protocol for her rehab, they should have owned up to their mistake or to a poor manufacturing technique. Almost 10 years ago, I had an upper gastrointestinal series performed to monitor my non-Hodgkin’s lymphoma. As a result of the biopsies, I experienced significant bleeding (the doctor said that he had done this procedure several times when the patient was still on blood thinners, which I was). After I was admitted to the emergency room and received four units of blood, they repeated the procedure — and charged me for all of it. Fortunately, after threatening a lawsuit against the hospital and the doctor, they finally paid for the emergency room and operating charges.

There still may be some relief for Ms. Witter: There are companies who audit hospital bills and get paid if they find savings. When the insurance company refused to pay the hospital, they should have referred her to a company that audits hospital bills.

— Dan Kass, chief shopper of HealthCare Shopping Network, Mission, Kan.

On Twitter, readers minced no words:

Well, what do you expect from a small piece of metal that costs $9,706? No wonder it broke.Bill Of The Month: $43,208 For Repeat Surgery To Replace Broken Medical Device https://t.co/MLHMIiP1Xo

— Bernie Good (@CBGood23) December 18, 2018

— Bernie Good, Pittsburgh

This is unconscionable. We need #SinglePayer now! Nobody should have to fight with insurance companies or foot the bill for a second surgery due to device failure. Bill Of The Month: $43,208 For Repeat Surgery To Replace Broken Medical Device https://t.co/VWM3ALKEhW

— Judy Melinek M.D. (@drjudymelinek) December 18, 2018

— Dr. Judy Melinek, San Francisco

A Dose Of Myth-Busting

Julie Appleby’s story “Short-Term Health Plans Hold Savings for Consumers, Profits For Brokers and Insurers” (Dec. 21) perpetuates a common misunderstanding that incentives for insurance agents favor selling short-term over Affordable Care Act plans.

By comparing a monthly commission rate of 20 percent for short-term plans and a flat dollar amount for ACA policies, the article mistakenly suggests that commission earnings on short-term plans are consistently higher than those that comply with the ACA. But the premise misses the critical fact that the lifetime value of a plan — not the monthly commission rate — determines insurance agent commissions. Short-term plans are both less expensive and held by the customer for a shorter period of time than ACA plans. At eHealth, an ACA plan generates twice the revenue as each short-term policy.

Most insurance agents advocate for consumers to choose an ACA plan first, if they can afford it, because the coverage is far more comprehensive. Unfortunately, many Americans have been priced out of the ACA market and short-term policies may represent the best viable health insurance coverage at a price they can afford. Others miss the open-enrollment period and, without other options, face a year with no insurance coverage at all. The responsibility of a good insurance agent is to help all Americans gain access to the insurance policy most suitable for their individual medical and financial needs. To do anything less is not in the best interest of consumers or to the long-term success of insurance agents.

— Scott Flanders, CEO of eHealth, Santa Clara, Calif.

Sad Twist On Knee Replacements

It’s true that doctors do not always tell you the reality of knee replacements upfront (“Up To A Third Of Knee Replacements Pack Pain And Regret,” Dec. 25). I had to have my right knee replaced twice. I had a metal allergy to the first implant, which I found out the hard way.

Patients should be tested for metal allergies before surgery. I am so sorry I ever had my knee replaced — it hurts worse now than it did before the surgery. I would not have my other knee replaced unless I could not walk. I was told my knee would be great until after my second surgery, when my surgeon warned me my knee would possibly always cause me pain. That would have been nice to know before my first surgery.

— Lesa Lawrence, Dallas

Usually we don't hear the downside of these procedures. But this percentage seems way too high. #meddevice #hipsnknees https://t.co/H7s9jOhXzy

— Greg Mays (@hips_n_knees) December 26, 2018

— Greg Mays, Nashville, Tenn.

Without knocking total knee arthroplasty, or TKA, a New Yorker wonders whether we’re moving in the right direction.

TKA definitely has room for improvement but no data I know that the robotics arms race now underway will help. Up To A Third Of Knee Replacements Pack Pain And Regret https://t.co/gaggQ6HnYp via @khnews

— wendy diller (@Wendydiller) December 28, 2018

— Wendy Diller, New York City

Doing The Math On Biologics

The article “Why The U.S. Remains The World’s Most Expensive Market For ‘Biologic’ Drugs” (Dec. 20) mentioned that Cosentyx costs about $15,000 in Europe versus almost $65,000 in the United States. If it is true that someone can purchase a three-month supply for personal use in Europe — and if a three-month supply, properly handled, has a shelf life greater than three months — it seems possible for Susie to go to Italy or somewhere in Europe every three months for an estimated cost of $6,000 a year or less (with tickets purchased in advance). Adding to her travel costs the $15,000 annual cost of the drug, which conveniently can be self-injected, she could still make out far better than paying $65,000 a year in the States. Just a thought.

— Abette Jones-Bey, Blue Bell, Pa.

A tweeter offered one explanation for the pricing disparity:

(Answer? The Pharma lobbyists spend a whole lot on congress people.) Why The U.S. Remains The Most Expensive Market For 'Biologic' Drugs In The World https://t.co/nyuTQQs8c3

— Elizabeth Henry (@HenryLeerhenry) December 19, 2018

— Elizabeth Henry, Olathe, Kan.

Sign-Up Season’s Unsung Heroes

Your article on navigators (“Short On Federal Funding, Obamacare Enrollment Navigators Switch Tactics,” Nov. 30) neglected to mention the group of professionals best suited to help consumers select appropriate health coverage: licensed insurance agents and brokers. Agents and brokers typically have more training and experience than navigators. They’re licensed by the states in which they work. The majority have been in business for more than 10 years.

Agents and brokers also work with their clients year-round, not just during the six-week open-enrollment period. A survey conducted by the Kaiser Family Foundation found that more than 70 percent of agents spend “most” or “a lot of” their time explaining coverage to their clients.  It’s no wonder that nearly 84 percent of adults who worked with agents and brokers when shopping for exchange coverage found them helpful — more than any other group offering assistance.

— Janet Trautwein, CEO of the National Association of Health Underwriters (NAHU), Washington, D.C.

It has nothing to do with the high cost of premiums!!!! Hello – Navigators it's not you! Short On Federal Funding, Obamacare Enrollment Navigators Switch Tactics https://t.co/GdPkTIl7AS via @khnews

— HAFA (@TheNolanGroup) December 5, 2018

— B. Ronnell Nolan, president and CEO of Health Agents for America, Baton Rouge, La.

Entrepreneurs Caught In The Middle

I fall into the situation described in Steven Findlay’s article “Health Insurance Costs Crushing Many People Who Don’t Get Federal Subsidies” (Dec. 14).

If you look at the typical costs for a family earning more than $100,400 a year who don’t qualify for subsidies, the cost is huge. Our current premiums for an ACA-compliant policy are about $1,400 a month with a combined $13,000 deductible for my wife and me (we are self-employed). If you have a “bad year” — say, a car accident where you are both hospitalized — your expenses jump to an estimated $29,800, or nearly 30 percent of your income. This seems to be the strategy of the health insurance companies, whereby they want health care pricing to be a fixed amount of total income. The way they get there is through lack of transparency.

After Supreme Court Chief Justice John Roberts cast the deciding vote around the constitutionality of the ACA “tax” for being uninsured, I left a great corporate job and have since started multiple companies and created jobs simply because getting health insurance through the ACA seemed certain. I am now in the position where I am wondering if I may have to stop my entrepreneurial activities and find a corporate gig again with insurance. I suspect I am not alone in this.

The continued ambiguity around this will have a stifling effect on people like us who are taking the risk to start businesses and create jobs.

— Mick Garrett, Fort Collins, Colo.

"The financial challenge for people […] has come into much sharper focus during the past year, as insurance premiums have spiked."

Hmm… Feel like I said something like this would happen at the first mention of ACA. Love parts of ACA, but…

https://t.co/YNJ9I8NA2H

— Clayton Mowrer (@claytonmowrer) December 18, 2018

— Clayton Mowrer, Kansas City, Mo.

Band-Aid Fixes To ACA Are Like Salt To The Wound

“Ask Emily” columnist Emily Bazar offers a worthy solution that may work for a number of folks and should be explored by those whose household income is slightly above 400 percent the federal poverty level (FPL) (“Without Obamacare Penalty, Think It’ll Be Nice To Drop Your Plan? Better Think Twice,” Dec. 5). But there is a break-even point that may make this solution undoable. Since FPL is a national measure, with just two states receiving an exception (Alaska and Hawaii) to the income ceiling, for anyone who resides in a state with a high cost of living, such adjustments to take-home pay can adversely impact their ability to afford other necessities of life.

Cost of living can vary widely by state or ZIP code, yet the income ceiling for ACA subsidies is set at the national level. Insurance premiums may also vary among counties and even ZIP codes within a state. Some call this market-based pricing or pricing based on an area’s ability to pay (higher average incomes equate to higher premium prices). Still others call it price-gouging. Yet again, the income ceiling is set at the national level.

I welcome any and all ideas that would allow more folks to obtain health insurance (which, by the way, does not guarantee health care coverage). Changes need to be made to the law to level the playing field for consumers. Until all consumers have access to coverage at the same price, with the same level of subsidy be it government or employer, then we truly are putting band-aids on a heart attack. Until your age, marital status, place where you live and size of your employer no longer hinder your ability to afford health insurance coverage, there will continue to be those left out and at risk.

Unfortunately, our elected representatives at both the state and national level have little stomach to face and fix the glitches and inequities in the ACA. Their only remedy, which comes in the form of a tax on the uninsured, has taken the ACA from a solution meant to bring health insurance to all Americans to a policy that relies on those who can’t afford health insurance and are excluded from the benefits of the ACA to fund it. Now that’s ironic.

— Susan Frangione, Rockville, Md.

Hectoring people to buy something they can't afford isn't just stupid – it's a form of shaming and mockery. Of course people want health insurance – but they'd like to buy food and shelter first.

— Rob Levine (@roblevine82) December 5, 2018

— Rob Levine, Minneapolis

What’s Really Hurting ACA Enrollment

I can tell you the real reason many Americans gave up on enrolling in an Obamacare plan this year (“Need Health Insurance? The Deadline Is Dec. 15,” Dec. 10).

I had a fairly good health insurance plan under the Affordable Care Act in 2014-15. In 2015, my income changed, and I was eligible for Medicaid under Illinois’ expansion of that federal-state program. However, in July 2018, Medicaid determined that I no longer qualified. I went online to the ACA marketplace to try to find an ACA plan I could afford. To my surprise, the plans available in 2014 were no longer available. The two dozen plans available in my area are not ideal. Some provide low coverage. Some are from carriers that almost all of my doctor groups do not accept. Even some “gold”-level plans have extremely high copays. Though my premium in 2018 did not increase much, it was offset by high hospital copays and burdensome deductible and coinsurance obligations. Prescription copays were percentage-based, not a dollar amount, which made it more expensive to pay for prescriptions.

This is all hurting many Americans in my income bracket. The drop in enrollment in ACA plans is because no one can afford most of these low-level coverage plans in the ACA marketplace. And almost all the ACA plans have limited access to providers, especially specialists, making getting medical treatment nearby difficult. The ACA has been changed and tweaked so that many Americans no longer can afford to buy any of the plans without going into debt if a serious illness arises.

— Lena Conway, Naperville, Ill.